Understanding and Living Well with Chronic

Pain
Pierre Morin, MD, PhD

Basel

Medical Models

Bio-medical model
Social determinant model
Bio-psycho-social model
Psychodynamic model
Positive psychology (Seligman), Positive health
model (Antonovsky)
Indigenous model
Recovery/Self-management model
Process model (Mindell)

Bio-medical model
Environment

Psychology

Biologic predisposition

Characteristics: unilinear; disease fully explains the illness; biological

determinants are both necessary and sufficient for disease its diagnosis
and cure; psychology may be a secondary influencing factor. There is no
explanation for illness without disease.

Disease

Illness

Clinical Outcome

Social determinant model

Diseases are influenced and caused
by social processes: Social status,
Rank, Social dynamics of prejudice
and marginalization based on
gender, race, sexual orientation etc
create ongoing stress which cause
disease.

Bio-psycho-social model

Environment
Psychosocialmodifiers

Biologic/predispositionDiseaseClinicalOutcome
Psychological

Illness

Illness and disease result from simultaneously interacting

systems at the cellular, tissue, organ, and interpersonal and
environmental levels

Psychodynamic model
Illness and disease have an adaptive
function. They are meaningful
processes that are embedded in a
persons individual and collective life
and environment. They are the best
solution so far and promote healing
and growth. Physiologic states are
metaphors for individual and social
processes.

Positive psychology/
Positive health model
What prevents us from getting ill physically and mentally?
What are the characteristics of people who stay healthy
despite adverse circumstances? What are the strengths
and virtues that act as buffers against illness? How do we
amplify and foster these strengths and virtues? Instead of
focusing on curing/treating pathologies positive
psychology/health sees health as a continuum and is
interested in the factors (resilience, sense of coherence,
meaningfulness) that give our lives purpose, allow us to
stay healthy and cope with our limited health.

Indigenous model
Relationship to Nature, the ancestors, the spirit
world is relevant for staying healthy.
Relationship dynamics are a relevant factor for
causing disease: jealousy, the evil eye, being
outcasted by the tribe etc

Recovery/Self-Management Model
I
Recovery is an individuals journey of
healing and transformation to live a
meaningful life in a community of his or
her choice while striving to achieve
maximum human potential.

Recovery/Self-Management Model
II
Clients have primary control over decisions
Based on concepts of strength and
empowerment
Provide education
Living with Symptoms instead of getting rid of
them
A meaningful life is possible despite
serious/chronic symptoms
Adaptation to issues of diversity

Recovery/Self-Management Model
III
Increasing knowledge about illness
Engaging in activities that promote
health
Coping more effectively and reducing
distress from symptoms
Reducing social exclusion
Increasing self-confidence

Process Model of Medicine

Procrustes and his bed:
ignoring/marginalizing dreamlike and
creative qualities of life allows us to
create a consensual everyday reality and
function in life. Marginalized realities
reappear imbedded in things we call
problems and symptoms.

Pain

Pain/Chronic Pain
Definition
An unpleasant sensation and an
emotional experience associated with a
real or potential damage to tissue, or the
equivalent of such damage.
Pain without apparent biological value
that has persisted beyond the normal
tissue healing time (usually taken to be 3
months)

Names
Amplified Musculoskeletal Pain, Reflex
Neurovascular Dystrophy, Reflex Sympathetic
Dystrophy, Sympathetically Maintained Pain,
Fibromyalgia, Algodystrophy, Complex
Regional Pain Syndrome Types I and II,
Causalgia, Sudecks Atrophy, Shoulder-Hand
Syndrome, Repetitive Strain Injury, Plantar
Fasciitis, Localized or Diffuse Idiopathic
Musculoskeletal Pain, Neuropathic Pain,
Central Pain, Psychogenic Pain, Psychosomatic
Pain

Epidemiology/Prevalence/Impact
9 - 11% of the U.S. population suffer from moderate to
severe chronic pain.
Women are more likely to suffer chronic pain than men.
On average it is present almost 6 days in a typical week.
Only of chronic pain sufferers say their pain is pretty
much under control.
Chronic pain is the most common complaint made by
patients to their Primary Care Providers.
It accounts for an estimated $75-$100 billion a year in
the U.S. in lost productivity and health care costs.

Specificity Theory of Pain:

The intensity of pain is directly related to the
amount of associated tissue injury. For
instance, pricking ones finger with a needle
produces minimal pain, whereas cutting ones
hand with a knife causes more tissue injury and
is more painful. This theory is generally
accurate when applied to certain types of
injuries and the acute pain associated with
them. It is inadequate to explain chronic pain.

Gate Control Theory:

Perception of physical pain is not a direct result of
activation of pain receptor neurons, but instead is
modulated by interaction between different neurons.
Before they can reach the brain pain messages
encounter nerve gates in the spinal cord that open or
close depending upon a number of factors (possibly
including instructions coming down from the brain).
When the gates are opening, pain messages get
through more or less easily and pain can be intense.
When the gates close, pain messages are prevented
from reaching the brain and may not even be
experienced.

Loessers Onion Theory of Pain:

This says that the pain mechanism is a
series of nested layers, like the ones of an
onion. The nerve stimulus or damage is
at the centre, the next layer is the
perception of pain, then come suffering,
pain behavior, and finally interaction
with the environment.

Nociceptive Pain:
Pain that is a result of tissue irritation, impending
injury, or actual tissue injury sensed by pain receptors.
Pain receptors are the nerves which sense and respond
to parts of the body which suffer from damage. When
activated, they transmit pain signals (via the peripheral
nerves as well as the spinal cord) to the brain. The pain
is typically well localized, constant, and often with an
aching or throbbing quality. Visceral pain is the
subtype of nociceptive pain that involves the internal
organs. It tends to be episodic and poorly localized.

Neuropathic Pain:
Can occur as a result of injury or disease to the
nerve tissue itself. This can disrupt the ability
of the sensory nerves to transmit correct
information to the thalamus, and hence the
brain interprets painful stimuli even though
there is no obvious or known physiologic cause
for the pain. Neuropathic pain is the disease of
pain. It is not the sole definition for chronic
pain, but does meet its criteria.

Referred Pain:
Is a phenomenon used to describe pain
perceived at a site adjacent to or at a
distance from the site of an injury's
origin. One of the best examples of this is
during heart attack. Even though the
heart is directly affected the pain is often
felt in the neck, shoulders and back
rather than the chest.

Sympathetically Maintained Pain:

This condition used to be called a reflex
sympathetic dystrophy. It is also known as
algodystrophy, Sudecks atrophy and a host of
other names. It is now called, by the
International Association for the Study of Pain,
a complex regional pain syndrome.
Sympathetically maintained pain is believed to
be maintained by the sympathetic nervous
system or by circulating catecholamine.

Peripheral and Central

Sensitization:
Amplification of pain stimuli produces
secondary heightened sensitivity.

Hyperalgesia:
Lowered pain threshold, which in one
form is caused by damage to pain
receptors in the body's soft tissues.
Conditioning studies have established
that it is possible to experience a learned
hyperalgesia.

Allodynia:
Meaning "other pain", is the perception of pain
caused by usually nonpainful stimuli, such as
touch or vibration. An example of allodynia is
when a person perceives light pressure or the
movement of clothes over the skin as painful,
whereas a healthy individual will not feel pain.
Several studies suggest that injury to the spinal
cord might lead to loss and re-distribution of
pain receptors and pain modulating neurons
leading to the new response.

Pain and Memory:

Conditioning and sensitization can be seen as a
learning process at different levels. In addition,
memory traces of pain get stuck in the brains
prefrontal cortex which controls emotion and
learning. Abnormal implicit memories of pain
and emotional associations will influence
associative learned behaviors, e.g. avoiding
certain movements which will increase the
chance to develop chronic pain.

Hebbian or Associative Learning

Any two cells or systems of cells that are
repeatedly active at the same time will
tend to become 'associated', so that
activity in one facilitates activity in the
other.

Long-term Potentiation
Long-lasting enhancement in communication
between two neurons that results from
stimulating them simultaneously. Since neurons
communicate via chemical synapses, and
because memories are believed to be stored
within these synapses, LTP and its opposing
process, long-term depression, are widely
considered the major cellular mechanisms that
underlie learning and memory.

Fear-Avoidance Model

Pain and Trauma/Abuse

Beliefs that trauma and pain are
unpredictable and uncontrollable.
Sense of feeling victimized by pain.
Fears and avoidance of activities that will
be painful.
Avoidance behaviors lead to inactivity
that will worsen pain.

Regaining Ownership/Control
Chronic pain as a trauma that needs to
be re-conquered.
Integrating Painmaker and
Traumatizer
Like Native Americans used to inflict
themselves with a wound once they had
been wounded by an adversary.

Psychological Assessments
Pain Questionnaire/Inventory
Depression/Learned Helplessness
Anxiety Sensitivity (fear of anxiety-related bodily
sensations)

Cognitive & Behavioral Avoidance

Coping Styles
Beliefs and Expectations
Self-efficacy/Sense of Coherence
PTSD Checklist/Abuse

DSM IV/Somatoform Disorder

Conversion disorder, hypochondriasis,
body dysmorphic disorder, pain disorder,
undifferentiated somatoform disorder,
somatization disorder.
(Not factitious disorder, malingering).

Multidisciplinary Pain
Treatment/Management

Medication/Pharmacotherapy
Physical Therapy, Occupational Therapy
Psychology
Retraining the Nervous System
Alternative/Complementary Medicine
Interventional Medicine
Self-management/Education

Medication
Over the Counter Medication (Acetaminophen,
Tylenol, Paracetamol)
NSAID (Ibuprofen/Advil)
Narcotics/Opioids (Morphine, Methadone,
Oxycodone, Oxycontin, Fentanyl)
N-Type Ca-Channel Blocker (Sea snail venom)
Na-Channel Blockers (Antikonvulsant)
Vanilloid/Capsaicin Receptor Blockers (Chili
pepper)
Antidepressants

Interventional Pain Management

Nerve Blocks
Spinal Cord Stimulation
Implantable Opioid Pumps

Ramachandran/Phantom
limb/Mirror box
A mirror box is a box with two mirrors in
the center (one facing each way) to help
alleviate pain.
The non-painful limb is projected onto
the hurting side in order to retrain the
brain, and thereby eliminate the learned
paralysis/pain.

Retraining the Brain

Vigorous exercise and talk therapy are
used to retrain pain patients brain to
recognize pain signals differently.

Self-management

Allopathic Medicine
Complementary Medicine
Allostasis/Stress-management/Relaxation
Advocacy/Empowerment/Rank/Leadership
Education/Behavioral changes
Family/Peer/Community support
Psychology/Picking up the energy
(painmaker/traumatizer)

Hierarchy and Health

Marmots Whitehall Study of British
Civil Servants
Hierarchy and Social Inequality leads to
more illness and early death
Allostasis/Allostatic Load: The burden of
cumulative adversity
Coping: Sense of Coherence

Health Disparity

Relative poverty
Disparity between the rich
and the poor: High gap correlates with
poor population health.

Social comparison: Feelings of

humiliation, resignation and shame affect our

stress physiologies.

Health Olympics/US Ranking

Life Expectancy:
Teen Birth:
Educational Opportunities:
Child Poverty:
Child Abuse Death Rates:
Child Injury Death Rates:

29
28
21
25
26
23

Rank
Rank reflects the underlying power differences
of the many hierarchies we use on a daily basis
to compare ourselves (Fuller, 2003).
Conscious or unconscious, social or personal
ability or power emerging from areas of sociocultural influence, personal psychology, and/or
spiritual ties (Mindell, 1995) .

Subjective Rank and Health

Rank Dimensions
Social Rank
Psychological Rank
Spiritual/Transpersonal Rank
Contextual Rank

Social Rank
Depends on ones position in regard to
mainstream values in the areas of sociocultural influence like gender, sexual
orientation, age, class, health/disability,
religion, ethnic identity/race etc

Psychological Rank
Includes self-love, self-confidence and
self-knowledge. It also stresses good
relationships skills, high in-group status,
and a loving support network.

Spiritual or Transpersonal Rank

Reflects ones sense of connectedness
with something spiritual and divine or
with something greater than yourself (e.g.
God, Nature).

Contextual Rank
Derives from ones momentary roles in a
given situation: as a teacher, health care
provider, parent, bank teller etc...

Signals of the Clinicians Higher Rank

An attitude of:
I know what is wrong with you!
You are sick, I am in good health!
I decide about the content, the setting and the
course of our interaction or therapy!
I can be empathic!
I decide how much of myself I reveal in the
relationship!
Detached and objective tone of voice, that reflect
our sense of superiority, self-confidence, selfesteem.

Signals of the Clinicians Higher Rank

In our capacity to sit back and relax; feel at ease,
comfortable and confident.
In our capacity to be verbally articulate and
expressive.
In our feeling of entitlement.
When we marginalize or dismiss our patients
thoughts and feelings, in comments like don't
take it so personally, you are too sensitive, etc.
When relationship issues arise and we think it is
the patients problem. We can't understand. We
think the patient is crazy, illogical, disturbed or
angry.

Signals of the Patients Lesser Rank

A tendency to settle for the way things are.
Feeling cloudy and unable to think.
Self-doubt, blame and insecurity, low self-esteem and
feeling of inferiority.
Adaptive behavior.
A tendency to placate, elevate, and compliment the other
person.
Signals of fear, like shaking, sweating, not able to look the
other in the eye.
Feelings of paranoia.
Body signals of agitation.
Feelings of revenge, jealousy, and anger. Tendency to be
emotional, upset, angry, loud, to feel misunderstood, and to
feel emotionally desperate.

Signals of the Patients Lesser Rank

Difficulty in taking a stand for oneself.

One feels overlooked, neglected and unnoticed.
One feels like ones position is insignificant and no
one else feels the same.
Little or no eye contact.
Shy or reserved.
Many pauses in the speech flow or not much
talking at all.
Poor motivation and compliance.
Stubbornness or insistence on ones position.

Circumstances with Innate Rank

Issues
With women who feel underprivileged in their
relationships.
With foreigners from underprivileged parts of the world.
With people with the sexual orientation of a minority.
With people with an obvious physical sign that
characterizes them as belonging to a disenfranchised
group of society (e.g. skin color, other physical stigmas)
With children and adolescents
With people suffering from chronic pain or other chronic
health problems

Barriers to Effective Pain

Management
Patient Attitudes

Clinician Attitudes

Cultural/Societal
Attitudes

Cultural and Personal Context of

Chronic Pain
Pain as a sub-culture experience
Chronic pain patients feel marginalized
from mainstream culture
Loss of social rank/status is a co-factor in
chronic pain
Sense of feeling traumatized by pain;
past history of abuse/trauma

Somebodies and Nobodies

Sense of being a nobody in social comparison
to others
Loss of status/rank because of illness and
other marginalizing processes
Sense of shame and humiliation, loss of
respect and dignity
Independent of individual psychology
Power of internalized social values

Cultural Metaphors
Blameworthy ill-health versus responsible
health
Health and illness as an individual process
Juvenile good-looking body equals
success; metaphor for fitness and
attractiveness and standard for social
acceptance and recognition
The body as a commodity

Biases and Stereotypes

Beliefs about addiction/Opiophobia
Beliefs about functional versus real
disease
Beliefs about health and healing
Beliefs about how much pain is ok
Beliefs about other healing modalities
Beliefs about good patient and bad patient

Clinician-Patient Relationship

Cultural competence/sensitivity
Rank awareness
Awareness of ones biases/stereotypes
Communication skills
Awareness of individual and social beliefs

Difficult/Complex Patient/Client

Hostile or defiant patient

Demanding patient
Patient with multiple chronic problems
Patient who somatizes
Patient with functional/ psychological
overlay

Clinical Competency in Chronic

Pain Treatment

Knowledge of systemic and social determinants.

Knowledge of beliefs and barriers to treatment.
Ability to mediate and facilitate complex issues.
Works as part of a multidisciplinary team.
Is an expert in communicative and
interpersonal skills.
Educates and chares decision making.

REFERENCES

Institute for Clinical Systems Improvement (ICSI). Assessment and

management of chronic pain. Bloomington (MN): Institute for Clinical
Systems Improvement (ICSI); 2005 Nov. 77 p.
Assessment and Treatment of Chronic Pain: By John Mark Disorbio,
EdD,
Daniel Bruns, PsyD,and Giancarlo Barolat, MD. Practical Pain
Management, March 2006.
Provider-Patient Interaction: Understanding Unconscious Interpersonal
Defensive Responses in a Chronic Pain Practice to Improve Interactions.
By Ron Lechnyr, Ph.D., DSW; Terri Lechnyr, MSW, LCSW. Practical
Pain Management, Mar/Apr 2004.
Fuller, R.W. Somebodies and Nobodies. Overcoming the Abuse of Rank.
Gabriola Island, BC: New Society Publishers, 2003.
Mindell, A. Sitting in the Fire: Portland: Lao Tse Press, 1995.
pierre@creativehealing.org
www.creativehealing.org